NSQHS Standards updates and consultations

Newly established health service organisations must undergo interim accreditation and be assessed within 10 working days from the commencement of service provision as described within NSQHS Standards Advisory AS18/02.

Where it is not possible for the assessment team to perform the final interim assessment on-site due to Covid-19 restrictions or public health orders, the accrediting agency may apply to the Commission to perform a hybrid assessment.

Organisations that have completed an interim assessment when operations were first commenced, are required to complete a full assessment to the NSQHS Standards within an 18 month period. This requirement is unchanged for organisations that are assessed as low risk for the transmission of COVID-19.

However, if an organisation that has undertaken an interim assessment is not a low risk health service, interim accreditation may be extended until an on-site assessment can be conducted.

Where it is not possible for the assessment team to perform the final interim assessment on-site due to public health orders or Covid-19 related restrictions, the accrediting agency may apply to the Commission to perform a hybrid assessment.

Where a hybrid assessment has been approved, but it is not possible for assessors to conduct the on-site component of the hybrid assessment, further approval may be sought from the Commission to conduct a virtual segment of the assessment. However, an onsite assessment MUST take place as soon as practically possible.

Where a health service organisation has undergone final interim assessment via the hybrid method and has met the requirements to be accredited, the accrediting agency may issue an accreditation certificate.

Where an assessment was solely conducted virtually, a subsequent on-site assessment must be conducted as soon as practicable thereafter to meet the requirements of a hybrid assessment.

If actions are found to be “not met” during the subsequent on-site assessment, the interim accreditation will be withdrawn and remediation processes instigated. 

If an organisation has actions which are not met at the final interim on-site assessment, there is a remediation period in which they must demonstrate sufficient change has been implemented for actions to be rated met or met with recommendations and to be awarded accreditation.

From 26 October 2020, assessments can resume for health service organisations with a low risk of COVID-19 transmission. Assessments will not be conducted in organisations where there are active COVID-19 clusters or state or territory restrictions or lockdowns. Restrictions on border crossings will also be taken into consideration.

Your accrediting agencies will work with you, the Commission and the relevant health department to confirm the organisations risk status, and schedule the next assessment.

Health service organisations will have 12 months added to their current accreditation expiry date. This means whatever month and year your current accreditation is due to expire, it will now expire in that month, one year later.

Your assessment should be scheduled with your accrediting agency to commence at least 4 months before your revised accreditation expires.

• Is not treating patients with active COVID-19
• Is not treating overseas or interstate travellers during their quarantine period
• Does not have (or does not suspect they have) a member of the workforce with COVID-19 which could have been transmitted to others in the organisation
• There is limited impact on the normal workforce being available for duty. Members of the workforce are not
  • In isolation due to possible or confirmed COVID-19 contact
  • Redeployed to support COVID-19 related activities within or across health service organisations
• The health service organisation is not directly affected by
  • A public order that has resulted in a lockdown or restriction of movement of citizens
  • Known active COVID-19 infections in the area
• The organisation is not supporting an aged care facility with active COVID-19 infections.

These risk criteria are provided as a guide and emerging and real circumstances of each service will be considered in real time when determining if a health service organisation is low risk and an assessment can proceed.

Organisations will not be disadvantaged because of COVID, if the risk level of an organisation changes and a final assessment cannot be rescheduled, the remediation period will be extended until the risk has reduced. The Commission will work with regulators, accrediting agencies and health service organisation to identify and manage instances where a review of the remediation period may be required.

When scheduling assessments, the Commission has asked accrediting agencies to prioritise:

• Organisations that have completed an initial assessment and are awaiting a final assessment to address any actions that were not met and required remediation
• Organisations that were previously scheduled for assessments from March 2020 and have not yet been assessed.

Your assessment should be scheduled at least four months before the revised accreditation expiry date.

Organisations that have completed an interim assessment when operations were first commenced, are required to complete a full assessment to the NSQHS Standards within an 18 month period. This requirement is unchanged for organisations that are assessed as low risk for the transmission of COVID-19.

However, if an organisation that has undertaken an interim assessment is not a low risk health service, interim accreditation will be maintained until an onsite assessment can be conducted.

It is preferable for assessments to be conducted using an assessment model with all assessors on site. However assessments can be conducted using a hybrid assessment methodology where some assessors are on site, and others review the organisation using videoconferencing technologies from a remote location.

Hybrid assessments can occur when assessors are unavailable to be onsite due to:

• Travel or border restrictions
• Locally available assessors.

In these cases, assessments that involve both onsite and remote assessors may be scheduled. However, 50% or more of the assessment team should be onsite.

The Commission has been working with accrediting agencies to ensure onsite assessments are as safe as possible for patients, the workforce and assessors. To this end, before entering your organisation, assessors will have:

• Completed additional infection prevention and control training
• Passed a screening checklist to ensure they have no signs or symptoms of a respiratory infection

Onsite assessors are also required to comply with any screening requirements put in place by the organisation they are visiting.

Health service organisations accredited to the NSQHS Standards will have an additional 12 months added to their current expiry date. This administrative action will be performed by the Commission and accrediting agencies, amended certificates will not be issued. Health service organisation could however seek a statement from their accrediting agency providing the same detail as that on a certificate if requested from their accrediting agency.

Enquiries please email the Advice Centre: accreditation@safetyandquality.gov.au or contact your accrediting agency.